INSTITUT PENGAJIAN SISWAZAH

INSTITUTE OF POSTGRADUATE STUDIES

Please ( ) at the space provided.
Checklist for documents that need to be submitted before registration.
(Applicable to international candidate only)
1. Form A
2. Three (3) certified copies of passport*
3. Four (4) passport size photographs (with blue background)
4. Medical Examination Report (1 set of form marked by For Immigration Purposes at
top right corner)
* passport with the validity date that covers the period of study.
Checklist for documents that need to be submitted during registration
1. Confirmation of registration form
2. Medical examination report and X-Ray report endorsed by the USM Wellness Centre
(1 set of form marked by For USM Wellness Centre at top right corner)
3. Smart Card application form
4. Change of address form (if necessary)
5. Copy of scholarship/sponsorship letter of offer
6. Health Insurance (Applicable to international candidate only)
7. Copy of latest bank statement -1 month prior to registration
(Applicable to international candidate only)
Checklist for original documents that candidate need to bring during registration
1. Original letter of admission
2. Original degree scrolls
3. Original academic transcript
4. Receipt of payment
5. Scholarship/sponsorship letter of offer (if any)
6. Student pass approval letter from the Malaysian Immigration (Applicable to international candidate)
UNIVERSITI SAINS MALAYSIA
Checklist For Registration
1
INSTITUT PENGAJIAN SISWAZAH
INSTITUTE OF POSTGRADUATE STUDIES
NAME:
ADDRESS:
POSTCODE: COUNTRY:
E-MAIL:
TELEPHONE: MOBILE:
DEAN
INSTITUTE OF POSTGRADUATE STUDIES
UNIVERSITI SAINS MALAYSIA
11800 PULAU PINANG
MALAYSIA
Confirmation Of Acceptance Offer Of Admission To Undertake Postgraduate Studies,
Universiti Sains Malaysia
I hereby confirm acceptance to undertake Postgraduate Studies at Universiti Sains Malaysia
Expected Date of Registration:
Date:
(Signature of candidate)
International Students are requested to enclose four (4) copies of passport size photos with blue
background and three (3) certified copies of pages of the passport together with this Form for the Student
Pass application. Please forward these documents to Institute of Postgraduate Studies, Universiti Sains
Malaysia, 11800 USM Penang, Malaysia.
FORM A
UNIVERSITI SAINS MALAYSIA
* Please complete the name and address in the box provided
Centre/School of Studies:
(Applicable to international candidate only)
2
MEDICAL EXAMINATION REPORT
FOR LOCAL / INTERNATIONAL STUDENT
AND ACCOMPANYING PERSON
PLEASE USE CAPITAL LETTERS
SECTION 1 (TO BE COMPLETED BY CANDIDATE)
(PART A)
FULL NAME (AS IN PASSPORT / IC)
INTERNATIONAL PASSPORT NO.
NATIONALITY
CONTACT NUMBER DATE OF BIRTH
MARITAL STATUS GENDER
AGE
MALE
FEMALE
SINGLE
MARRIED
ACADEMIC YEAR
/
SCHOOL / CENTRE
PROGRAMME
MASTER
DOCTORATE
NEXT OF KIN
NEXT OF KINS ADDRESS
NEXT OF KINS CONTACT NUMBER
D D M M Y Y
Affix
passport size
photo here
1B/5
UNIVERSITI SAINS MALAYSIA
I/C NO.
For Immigration purposes
(Applicable to international candidate only)
3
SECTION 1
(PART B) - Please tick (

) in the relevant box
Declaration of self and family illness. Explain in full if you or your family has any of the following illness.
Immediate family refers to father, mother, brothers / sisters
MEDICAL PROBLEMS
SELF IMMEDIATE
FAMILY
1. Congenital or inherited disorder
2. Allergy
3. Mental illness
3. Fits, stroke, other neurological disease
5. Diabetes Mellitus
6. Hypertension
7. Heart or vascular disease
8. Asthma
9. Thyroid disease
10. Kidney disease
11. Cancer
12. Tuberculosis
13. Drug addiction
14. AIDS, HIV
15. History of surgery
16. Other illness
Yes No
If Yes please state
Yes No
Current medication (Long term)
IMMUNISATION HISTORY
(where applicable)
1. Yellow Fever
2. BCG*
3. Meningitis (Quadrivalent)*
4. Hepatities B*
5. Others
DATE IMMUNISED
I hereby certify that the information given above is true. I understand that my application will be rejected
if there is any false information given.
Date Signature of candidate
2B/5
* Applicable for international candidates only.
For Immigration purposes
(Applicable to international candidate only)
4
For Immigration purposes
(Applicable to international candidate only)
SECTION 2 - PHYSICAL EXAMINATION
To be filled by examining doctor
1. BASIC MEASUREMENT
HEIGHT : m
WEIGHT : kg
VISION TEST : Unaided : (R) (L)
Aided : (R) (L)
2. GENERAL EXAMINATION
a. DEFORMITIES
b. PALLOR
c. CYANOSIS
d. JAUNDICE
e. OEDEMA
f. SKIN DISEASES
YES NO COMMENT ITEM
BLOOD PRESURE : mmHg
PULSE RATE : / min
COLOUR VISION TEST :
NORMAL / ABNORMAL
3. SYSTEM EXAMINATION
a. EYES (Including funduscopy)
b. EARS
c. NOSE
d. ORAL CAVITY / THROAT
e NECK
f. HEART
g. LUNGS
h. ABDOMEN / HERNIAL ORIFICES
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
NORMAL ABNORMAL COMMENT ITEM
3B/5
5
For Immigration purposes
(Applicable to international candidate only) SECTION 3 - INVESTIGATIONS
To be filled by examining doctor.
URINE TEST
a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
d. MORPHINE*
e. CANNABIS*
f. AMPHETAMINES TYPE STIMULANT
DATE TAKEN RESULT ITEM
BLOOD TEST (Applicable for international candidates only)
a. HEPATITIS Bs ANTIGEN
b. HEPATITIS C
c. HIV
d. VDRL / TPHA
e. MALARIAL PARASITE
DATE TAKEN RESULT ITEM
CHEST X-RAY INFORMATION
CHEST X-RAY NO.
DATE TAKEN
PLACE TAKEN
REPORT
4B/5
* Applicable for international candidates only.
6
SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR
Please tick (

) in the appropriate box
I certify that I have on this date examined
Mr. / Ms.
IC / Passport No. and found him / her:-
IN GOOD
HAVING THE FOLLOWING MEDICAL COMPLICATION(S) (Please State)
UNDERGOING TREATMENT FOR: (Please State)
Date: Signature of Doctor :
Name of Doctor :
Qualification :
Hospital / Clinic :
Registration Number
Official Stamp :
Remarks By University / College Official:
5B/5
For Immigration purposes
(Applicable to international candidate only)
7
MEDICAL EXAMINATION REPORT
FOR LOCAL / INTERNATIONAL STUDENT
AND ACCOMPANYING PERSON
PLEASE USE CAPITAL LETTERS
SECTION 1 (TO BE COMPLETED BY CANDIDATE)
(PART A)
FULL NAME (AS IN PASSPORT / IC)
INTERNATIONAL PASSPORT NO.
NATIONALITY
CONTACT NUMBER DATE OF BIRTH
MARITAL STATUS GENDER
AGE
MALE
FEMALE
SINGLE
MARRIED
ACADEMIC YEAR
/
SCHOOL / CENTRE
PROGRAMME
MASTER
DOCTORATE
NEXT OF KIN
NEXT OF KINS ADDRESS
NEXT OF KINS CONTACT NUMBER
D D M M Y Y
Affix
passport size
photo here
1A/5
UNIVERSITI SAINS MALAYSIA
I/C NO.
For USM Wellness Centre
8
SECTION 1
(PART B) - Please tick (

) in the relevant box
Declaration of self and family illness. Explain in full if you or your family has any of the following illness.
Immediate family refers to father, mother, brothers / sisters
MEDICAL PROBLEMS
SELF IMMEDIATE
FAMILY
1. Congenital or inherited disorder
2. Allergy
3. Mental illness
3. Fits, stroke, other neurological disease
5. Diabetes Mellitus
6. Hypertension
7. Heart or vascular disease
8. Asthma
9. Thyroid disease
10. Kidney disease
11. Cancer
12. Tuberculosis
13. Drug addiction
14. AIDS, HIV
15. History of surgery
16. Other illness
Yes No
If Yes please state
Yes No
Current medication (Long term)
IMMUNISATION HISTORY
(where applicable)
1. Yellow Fever
2. BCG*
3. Meningitis (Quadrivalent)*
4. Hepatities B*
5. Others
DATE IMMUNISED
I hereby certify that the information given above is true. I understand that my application will be rejected
if there is any false information given.
Date Signature of candidate
2A/5
* Applicable for international candidates only.
For USM Wellness Centre
9
SECTION 2 - PHYSICAL EXAMINATION
To be filled by examining doctor
1. BASIC MEASUREMENT
HEIGHT : m
WEIGHT : kg
VISION TEST : Unaided : (R) (L)
Aided : (R) (L)
2. GENERAL EXAMINATION
a. DEFORMITIES
b. PALLOR
c. CYANOSIS
d. JAUNDICE
e. OEDEMA
f. SKIN DISEASES
YES NO COMMENT ITEM
BLOOD PRESURE : mmHg
PULSE RATE : / min
COLOUR VISION TEST :
NORMAL / ABNORMAL
3. SYSTEM EXAMINATION
a. EYES (Including funduscopy)
b. EARS
c. NOSE
d. ORAL CAVITY / THROAT
e NECK
f. HEART
g. LUNGS
h. ABDOMEN / HERNIAL ORIFICES
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
NORMAL ABNORMAL COMMENT ITEM
3A/5
For USM Wellness Centre
10
SECTION 3 - INVESTIGATIONS
To be filled by examining doctor.
URINE TEST
a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
d. MORPHINE*
e. CANNABIS*
f. AMPHETAMINES TYPE STIMULANT
DATE TAKEN RESULT ITEM
BLOOD TEST (Applicable for international candidates only)
a. HEPATITIS Bs ANTIGEN
b. HEPATITIS C
c. HIV
d. VDRL / TPHA
e. MALARIAL PARASITE
DATE TAKEN RESULT ITEM
CHEST X-RAY INFORMATION
CHEST X-RAY NO.
DATE TAKEN
PLACE TAKEN
REPORT
4A/5
* Applicable for international candidates only.
For USM Wellness Centre
11
SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR
Please tick (

) in the appropriate box
I certify that I have on this date examined
Mr. / Ms.
IC / Passport No. and found him / her:-
IN GOOD
HAVING THE FOLLOWING MEDICAL COMPLICATION(S) (Please State)
UNDERGOING TREATMENT FOR: (Please State)
Date: Signature of Doctor :
Name of Doctor :
Qualification :
Hospital / Clinic :
Registration Number
Official Stamp :
Remarks By University / College Official:
5A/5
For USM Wellness Centre
12
BORANG PENGESAHAN PENDAFTARAN
(CONFIRMATION OF REGISTRATION FORM)
NAMA PENUH / (FULL NAME):
NO. KAD PENGENALAN /( I/C NO.):
NO. PASPORT/(PASSPORT NO.):
PUSAT PENGAJIAN / PUSAT / INSTITUT (SCHOOL / CENTRE / INSTITUTE)
A. IJAZAH (DEGREE)
DOKTOR FALSAFAH / KEDOKTORAN (PhD / Doctoral)
SARJANA (Masters)
B. JENIS PENCALONAN (CANDIDATURE TYPE)
PENUH MASA (Full Time) SAMBILAN (Part Time)
Dengan ini saya bersetuju bahawa tesis yang dihasilkan oleh saya adalah hakcipta
mutlak Universiti Sains Malaysia dan bukannya hakcipta penulis.
(I agree that my thesis is the permanent property of Universiti Sains Malaysia and the
copyright in its original form rests with the University and not with the author.)
Saya telah menerima senaskah Buku Panduan Pelajar
(I have received a copy of the Student Handbook)
Tarihk (Date):
Tandatangan Calon (Signature of Candidate)
UNTUK KEGUNAAN INSTITUT PENGAJIAN SISWAZAH
Tarikh Pendaftaran
Pengesahan Staf IPS
(For IPS Office Use Only)
Pengakuan Pelajar / (Declaration)
INSTITUT PENGAJIAN SISWAZAH
INSTITUTE OF POSTGRADUATE STUDIES UNIVERSITI SAINS MALAYSIA
13
1. NAMA (DALAM HURUF BESAR) / NAME (IN CAPITAL)
2. NO. MATRIK (MATRIC NO.)
3. NO. KAD PENGENALAN (PASSPORT @ I/C NO.)
BANDAR (STATE)
BORANG MENUKAR ALAMAT
(CHANGE OF ADDRESS)
4. ALAMAT SURAT MENYURAT (CORRESPONDENCE ADDRESS)
POSKOD (POSTCODE) NO. TELEFON (TELEPHONE NO.)
BANDAR (STATE)
5. BUTIR-BUTIR ALAMAT TETAP (PERMANENT ADDRESS)
POSKOD (POSTCODE) NO. TELEFON (TELEPHONE NO.)
Tarikh / (Date):
Tandatangan (Signature)
KEGUNAAN PEJABAT (FOR OFFICE USE ONLY)
Nama & Tandatangan
Tindakan oleh:
Tarikh
INSTITUT PENGAJIAN SISWAZAH
INSTITUTE OF POSTGRADUATE STUDIES UNIVERSITI SAINS MALAYSIA
NEGARA (COUNTRY)
NEGARA (COUNTRY)
14
BORANG PERMOHONAN KAD PINTAR
(SMART CARD APPLICATION FORM)
NAMA PEMOHON / (APPLICANTS NAME):
NO. MATRIK /(MATRIC NO.):
Tandatangan Pelajar (Signature of Student)
KEGUNAAN PEJABAT (FOR OFFICE USE ONLY)
Tarikh / (Date):
1. PENDAFTARAN DIRI LENGKAP TIDAK LENGKAP
Tandatangan Staf
Tarikh
2. PENGESAHAN SEMULA PERKARA YANG TIDAK LENGKAP
Disahkan oleh
Tarikh
KEGUNAAN PEJABAT (FOR OFFICE USE ONLY)
1. SESI FOTOGRAFI BERJAYA TIDAK BERJAYA
KOD BAR
2. KAD PINTAR DIAMBIL PADA
Disahkan oleh
Tarikh
Sila bawa bersama borang ini semasa mengambil kad pintar
(Please bring along this form during collection of the smart card)
12 huruf sahaja /(12 characters only)
INSTITUT PENGAJIAN SISWAZAH
INSTITUTE OF POSTGRADUATE STUDIES UNIVERSITI SAINS MALAYSIA
15
Institute of Postgraduate Studies
Universiti Sains Malaysia
11800 USM
Penang, MALAYSIA.
email: dean_ips@usm.my
www.ips.usm.my